10 against cerebral hemorrhage afforded by sleep is decidedly less than might have been supposed, and one cannot help thinking that the rise of blood pressure that must accompany the violent agonies of many bad dreams, and especially of Nightmares, is probably related to this fact. Vaschide and Marchand' have found that the blood pressure rises 25 mm. during an Angst attack in the waking state, and this, though clinically and pathogenetically akin to it, is much less severe than a Nightmare attack. Kornfeld's observations led him to conclude that the rise of blood pressure constitutes the chief symptom of an Angst attack, and that the extent of this rise is the most accurate measure of the intensity of the attack. Thus the unanimous opinions of the older authors, from Paulus Aeginata" and Avicenna" to Boerhaave," Bond," Macnish," Arbuthnot," Forbes Winslow," Hammond" and Foville," concerning the important part played by Nightmares in the causation of apoplexy, may have had a very considerable backing of truth. On the mental side, the frequency with which attacks of Nightmare precede or accompany the development of hysteria and insanity has been noted by the majority of writers on the subject." • Vaschide and Marchand. Contribution à l'étude de la psycho-physiologie des émotions à propos d'un cas d'éreuthophobie. Rev. de Psychiatr. juillet, 1900, T. III, p. 193, and Ufficio che le condizioni mentali hanno sulle modificazioni della respirazione e della circolazione periferica. Rivist. sper. di Fren., 1900, Vol. XXVI, p. 512. 10 Kornfeld. Centralbl. f. d. ges. Therap., 1902, No. 11, u. 12. "Paulus Aeginata. Op. cit., p. 388. "Avicenna. Cited by Motet in Jaccoud's Nouveau Dictionnaire, 1867, T. VI. Art. Cauchemar. 13 Boerhaave. Aph. 1020. 14 Bond. An Essay on the Incubus, or Nightmare, 1753, pp. 64, 65, 69. 18 Macnish. The Philosophy of Sleep, 1834, p. 138. 16 Arbuthnot. On the Nature and Choice of Aliments. 17 Forbes Winslow. On Obscure Diseases of the Brain and Disorders of the Mind, 1860, p. 611. 18 20 Hammond. Sleep and its Derangements, 1869, p. 149. 19 Foville. Cited by Hodgkin. Brit. Med. Journ., May 16, 1863, p. 502. 'Cubasch. Der Alp, 1877, S. 8. Waller. A Treatise on the Incubus, or Nightmare, 1816, p. 7. Kelle. Du Sommeil et ses accidents en général et en particular chez les épileptiques et chez les hystériques. Thèse de Paris, 1900, Nr. 254, Ch. III. Chaslin. Du role du rêve dans l'évolution du délire, 1887, pp. 40, 44, 46, 54. Vaschide et Piéron. La psychologie du Consideration of the actual relation of it to these affections will be postponed until some conclusion has been reached on more preliminary questions. Before entering on a discussion of the pathogenesis of the condition it will be well to consider in some detail its clinical characteristics and to define its essential features. Striking descriptions of the condition have been given by Psellus," Hammond," Radestock" and many others. As the most graphic accounts, impossible to surpass, have been given by selfsufferers I will quote from some of the more interesting of these sources and then attempt to summarize the most salient of the characteristics there described. Bond," a century and a half ago, tersely described the chief features of the condition as follows: "The Nightmare generally seizes people sleeping on their backs, and often begins with frightful dreams, which are soon succeeded by a difficult respiration, a violent oppression on the breast, and a total privation of voluntary motion. In this agony they sigh, groan, utter indistinct sounds, and remain in the jaws of death, till, by the utmost efforts of nature, or some external assistance, they escape out of that dreadful torpid state. As soon as they shake off that vast oppression, and are able to move the body, they are affected with a strong Palpitation, great Anxiety, Languor, and Uneasiness; which symptoms gradually abate, and are succeeded by the pleasing reflection of having escaped such imminent danger." The picture painted by Macnish" is so vivid in its coloring as to deserve reproduction if only for its literary interest. "Imagination cannot conceive the horrors it frequently gives rise to, or language describe them in adequate terms. They are a thousand times more frightful than the visions conjured up by necromancy rêve, 1902, Ch. IV et V. Escande de Messières. Les rêves chez les hystériques. Thèse de Bordeaux, 1895. Sante de Sanctis. I sogni, studi psycologici e clinici di un alienista, 1899, pp. 140-172. Esquirol. Des maladies mentales, 1832, T. II, Ch. XXI. Vaschide et Meunier. Rev. de Psychiatrie, Fév., 1901, p. 38. Lhomme. Ann. méd.-psych., 4e série, T. II, p. 238. Janet. Névroses et idées fixes, 1898, T. I, Ch. II et IV, etc. "Psellus. Opus medicum. 23 Radestock. Schlaf und Traum, 1879, S. 126, 127. or diablerie; and far transcend every thing in history or romance, from the fable of the writhing and asp-encircled Laocoon to Dante's appalling picture of Ugolino and his famished offspring, or the hidden tortures of the Spanish Inquisition. The whole mind, during the paroxysm, is wrought up to a pitch of unutterable despair; a spell is laid upon the faculties, which freezes them into inaction; and the wretched victim feels as if pent alive in his coffin, or overpowered by resistless and unmitigable pressure. "The modifications which nightmare assumes are infinite; but one passion is almost never absent—that of utter and incomprehensible dread. Sometimes the sufferer is buried beneath overwhelming rocks, which crush him on all sides, but still leave him with a miserable consciousness of his situation. Sometimes he is involved in the coils of a horrid, slimy monster, whose eyes have the phosphorescent glare of the sepulchre, and whose breath is poisonous as the marsh of Lerna. Everything horrible, disgusting or terrific in the physical or moral world, is brought before him in fearful array; he is hissed at by serpents, tortured by demons, stunned by the hollow voices and cold touch of apparitions. A mighty stone is laid upon his breast, and crushes him to the ground in helpless agony: mad bulls and tigers pursue his palsied footsteps: the unearthly shrieks and gibberish of hags, witches, and fiends float around him. In whatever situation he may be placed, he feels superlatively wretched: he is Ixion working for ages at his wheel he is Sisyphus rolling his eternal stone: he is stretched upon the iron bed of Procrustes: he is prostrated by inevitable destiny beneath the approaching wheels of the Car of Juggernaut. At one moment he may have the consciousness of a malignant demon being at his side: then to shun the sight of so appalling an object, he will close his eyes, but still the fearful being makes its presence known; for its icy breath is felt diffusing itself over his visage, and he knows that he is face to face with a fiend. Then, if he looks up, he beholds horrid eyes glaring upon him, and an aspect of hell grinning at him with even more than hellish malice. Or, he may have the idea of a monstrous hag squatted upon his breast-mute, motionless and malignant; an incarnation of the evil spirit-whose intolerable weight crushes the breath out of his body, and whose fixed, deadly, incessant stare petrifies him with horror and makes his very existence insufferable. "In every instance, there is a sense of oppression and helplessness; and the extent to which these are carried, varies according to the violence of the paroxysm. The individual never feels himself a free agent; on the contrary he is spell-bound by some enchantment, and remains an unresisting victim for malice to work its will upon. He can neither breathe, nor walk, nor run, with his wonted facility. If pursued by any imminent danger, he can hardly drag one limb after another; if engaged in combat, his blows are utterly ineffective; if involved in the fangs of any animal, or in the grasp of an enemy, extrication is impossible. He struggles, he pants, he toils, but it is all in vain: his muscles are rebels to the will, and refuse to obey its calls. In no case is there a sense of complete freedom: the benumbing stupor never departs from him; and his whole being is locked up in one mighty spasm. Sometimes he is forcing himself through an aperture too small for the reception of his body, and is there arrested and tortured by the pangs of suffocation produced by the pressure to which he is exposed; or he loses his way in a narrow labyrinth, and gets involved in its contracted and inextricable mazes; or he is entombed alive in a sepulchre, beside the mouldering dead. There is, in most cases an intense reality in all that he sees, or hears, or feels. The aspects of the hideous phantoms which harass his imagination are bold and defined; the sounds which greet his ear appallingly distinct; and when any dimness or confusion of imagery does prevail, it is of the most fearful kind, leaving nothing but dreary and miserable impressions behind it." A more accurate and no less graphic account is given by Motet.* "Au milieu du sommeil, le dormeur est pris tout à coup d'un profond malaise, il se sent suffoqué, il fait de vains efforts pour inspirer largement l'air qui lui manque, et il semble que tout son appareil respiratoire soit frappé d'immobilité. Ce qui pour le rêveur est le plus pénible, c'est le sentiment de son impuissance. Il voudrait lutter contre ce qui l'opprime, il sent qu'il ne peut ni se mouvoir ni crier. Des ennemis menaçants l'enveloppent de tous côtés, des armes s'opposent à sa fuite, il entrevoit un moyen de salut, il s'épuise en vains efforts pour l'atteindre. D'autres fois il se sent entraîné dans une course rapide; il voudrait s'arrêter, un gouffre "Motet. Jaccoud's Nouveau Dictionnaire de Méd. et de Chir. pratiques, 1867, T. VI. Art. Cauchemar. béant s'entrouve sous ses pas, il est précipité, et le sommeil s'interrompt après une violente secousse, comme celle que produit, dans la veille, une chute, un faux pas. Tout ce que l'esprit peut inventer de dangers, tout ce qu'il y a de plus effrayant, se présente dans le cauchemar. La sensation la plus habituelle, est celle d'un corps lourd qui comprime le creux épigastrique. Ce corps peut prendre toute sorte d'aspects; ordinairement c'est un nain difforme qui vient s'asseoir sur la poitrine et regarde avec des yeux menaçants. Chez quelques personnes la sensation pénible est, pour ainsi dire, prévue. Le cauchemar commence par une véritable hallucination; l'être qui va sauter sur la poitrine (éphialte) est aperçu dans la chambre, on le voit venir, on voudrait pouvoir lui échapper, et déjà l'immobilité est absolue; il bondit sur le lit, on voit ses traits grimaçants, il s'avance et quand il a pris sa place accoutumée, le cauchemar arrive à son summum d'intensité. A ce moment le corps est couvert de sueur, l'anxiété est extrême; parfois s'échappent des cris, des gémissements, et enfin un réveil brusque, accompagné le plus souvent d'un mouvement violent, termine cette scène de terreur." From these and other descriptions we may say that the three cardinal features of the malady are (1) agonizing dread; (2) sense of oppression or weight at the chest which alarmingly interferes with respiration; (3) conviction of helpless paralysis. Other accessory features are commonly present as well, but they will be discussed after the just mentioned triad has been considered in more detail. The dread that occurs in Nightmare and in other unpleasant dreams is best denoted by the German word Angst, for there is in English no term that indicates the precise combination of fearful apprehension, of panic-stricken terror, of awful anxiety, dread and anguish that goes to make up the emotion of which we are treating. The striking characteristic of it in pronounced cases of Nightmare is its appalling intensity. Shakspere well appreciated this, as is shown by Clarence's outburst on awaking from such a dream." As I am a Christian faithful man I would not spend another such a night, "King Richard the Third. Act I, Sc. 4, 1. 4. |